EINet Alert ~ Mar 12, 2010

*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and
notifications for emerging infections affecting the APEC member economies. It
was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:

Global: WHO situation update on pandemic influenza H1N1As of 7 March 2010, worldwide more than 213 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including at least 16,713 deaths.

The most active areas of pandemic influenza transmission are currently in Southeast Asia, however, lower levels of pandemic virus circulation persist in other parts of Asia and in Eastern and South-eastern Europe. In West Africa, limited data suggests that pandemic influenza virus transmission may be increasing in the region. Of note, seasonal influenza B viruses have been increasingly detected in Asia and appear to be spreading westward.

In Sub-Saharan Africa, limited data suggests that on-going community transmission of pandemic influenza virus continues to increase in parts of West Africa, without clear evidence of a peak in activity. Increased detections of pandemic influenza virus have been observed among sentinel surveillance sites in several countries, including Senegal and Cote D'Ivoire, however, to date, data is limited regarding the spectrum of clinical severity of cases. Recent increases in influenza activity have also been reported in Rwanda. Much of eastern and southern Africa likely experienced an earlier peak in pandemic influenza activity during November 2009 and late summer 2009, respectively.

In South and Southeast Asia, pandemic influenza virus circulation persist in most countries, however, overall transmission remains most active in Thailand, especially since mid January 2010. Approximately half of all provinces in Thailand reported that greater than 10% of all outpatients sought care for ILI, and approximately 25% of all patients with ILI at sentinel sites tested positive for influenza. The current increase in the number of cases in Thailand remains well below an earlier period of peak transmission during June through September 2009. In Bangladesh, an increasing trend in respiratory disease was reported; however, overall influenza activity remains low. In India, influenza virus transmission persists at lower levels in the western region of India, while activity in other regions has largely subsided.

In East Asia, pandemic influenza activity continues to decrease or remain low as levels of ILI return to seasonal baselines in Japan and in the Republic of Korea. In Mongolia, a recent sharp increase in ILI activity was associated predominantly with a resurgence of circulation of seasonal influenza B viruses. In China, pandemic influenza activity has declined since peaking during November 2009, however, overall influenza activity remains elevated, largely due to an increase in the circulation of seasonal influenza B viruses.

In North Africa and Western Asia, overall pandemic influenza activity remains low in most places, with the exception of Iraq and Afghanistan, both of which reported regional spread of influenza with an increasing trend in respiratory diseases activity. In Afghanistan, a moderate impact on the healthcare system was reported in association with increased respiratory disease activity. Although overall influenza activity remains low in Iran, all recent influenza virus detection has been due to seasonal influenza B viruses.

In Europe, overall pandemic influenza transmission continued to decline as low levels of pandemic virus continue to circulate in parts of eastern and south-eastern Europe. The overall percentage of sentinel respiratory specimens testing positive for influenza remained low (6.8%) but slightly increased compared to the previous week. Pandemic H1N1 2009 virus continues to be the predominant circulating influenza virus in the European region with the exception of the Russian Federation and Sweden where influenza B was reported as co-dominant or dominant.

In the northern and the southern temperate zones of the Americas, overall pandemic influenza transmission remained low as influenza virus continued to circulate at low levels. In Central America, Nicaragua and Honduras, reported slight increases in respiratory disease activity, possibly due to an increase in school outbreaks; however, it is unclear to what extent the increases are associated with circulation of pandemic influenza virus. In Brazil, an increasing trend of respiratory diseases with low overall intensity was reported in association with regional spread of influenza virus.

In the temperate zone of the southern hemisphere, overall influenza activity remained low, with sporadic detections of pandemic and seasonal influenza viruses.

Although pandemic influenza virus continues to be the predominant circulating influenza virus worldwide, circulation of seasonal influenza B viruses continue to increase and spread across Asia, parts of Eastern Europe, and Eastern Africa, but most notably in China, Mongolia, Iran and the Russian Federation.
(WHO 3/12/2010)

Europe/Near EastEgypt: New strategy to curb avian influenza H5N1 spreadIn the wake of rising human H5N1 avian influenza outbreaks, coupled with an increasing number of outbreaks in poultry, Egypt's health ministry said it is implementing new measures to curb the spread of the virus, including restricting the sale of poultry across governorate borders, the United Nations' Integrated Regional Information Networks (IRIN) reported. The health ministry said it will also launch a campaign to warn the public about the risk of raising poultry at home and will stop vaccinating poultry, because the practice has not curbed the spread of the disease, according to IRIN. Egypt has reported several dozen poultry outbreaks so far this year, most of them in household birds. The country has also experienced a surge in human cases since the first of the year, with 14 so far, including three deaths, according to a recent update from the WHO.
(CIDRAP 3/8/2010)

Europe: ECDC sees another pandemic influenza wave as unlikelyEuropean countries won't likely experience another wave of pandemic H1N1 influenza cases this spring and summer, though the virus will probably continue to circulate and be the region's dominant strain for the next flu season, the European Centre for Disease Prevention and Control (ECDC) said 9 March 2010. The agency made the predictions in an 18-page risk-assessment report designed to help countries adjust their vaccine and flu-response strategies over the coming months. However, the ECDC warned that the outlook could change if there are "significant unrecognized uninfected populations" or if the pandemic virus changes to become more transmissible.

The ECDC based its predictions on advice from influenza experts, findings from the few serologic studies that have been done, events during previous pandemics, and mathematical modeling work that attempts to estimate the number of people that have already been infected or have some immunity.

It says the extent of transmission in European countries has been difficult to determine. So far, there have been few published serologic studies. One of the first large-scale serologic studies of the pandemic virus was conducted by researchers from England's Health Protection Agency, who found that one in three children were infected in hard-hit areas, 10 times higher than surveillance estimates.
(CIDRAP 3/9/2010)

Netherlands: Dutch officials seek to return surplus pandemic influenza H1N1 vaccineThe Dutch health ministry has signaled that it is in talks with GlaxoSmithKline to possibly return a large portion of its surplus H1N1 flu vaccine. The ministry had ordered 34 million doses at a time when experts thought each person would need two doses. Of that total, 11 million doses have been administered, and the government is holding 2.2 million as an emergency reserve.
(CIDRAP 3/8/2010)

Spain: Nation to give pandemic influenza H1N1 vaccine to Latin AmericaSpain plans to donate four million doses of H1N1 vaccine to the countries of Latin America, the Pan American Health Organization (PAHO) announced recently. Trinidad Jimenez, Spain's minister of health, announced the donation at a 4 March 2010 meeting with Dr. Socorro Gross, assistant director of PAHO.
(CIDRAP 3/8/2010)

Turkey: Nation seeks to return some pandemic influenza H1N1 vaccine dosesTurkey is negotiating with vaccine companies to return some of its unused doses of H1N1 flu vaccine. Health Minister Recep Akdag said the government had ordered 43 million doses of vaccine but actually purchased 17 million. Officials are talking with manufacturers about giving "a significant part" of that amount back, but will keep two to three million doses for emergencies, he said.
(CIDRAP 3/9/2010)

United Kingdom: Electronic health records helped vaccination programBritain's system of electronic health records made it easier for medical providers to notify people targeted for H1N1 vaccination than was the case for US providers, said CDC Director Thomas Frieden at a recent conference. While Americans mostly decided on their own if and when to get vaccinated, British providers used the electronic records to identify people with high-risk conditions and invited them to come in for vaccination, he said.
(CIDRAP 3/8/2010)

AsiaIndia: Pandemic influenza H1N1 vaccine campaign set to launchIndia's health ministry said the country will begin vaccinating its priority groups against the pandemic H1N1 virus next week. Doctors and paramedics will be among the first to receive the vaccine. India has purchased 1.5 million doses from Sanofi and had asked the company to conduct a pandemic vaccine trial in India, which it has completed and sent to the ministry. Indian companies are also working on pandemic H1N1 vaccines.
(CIDRAP 3/10/2010)

Thailand: 212 confirmed pandemic influenza H1N1 deathsType-A (H1N1) influenza has caused three more deaths and infected 937 more people over a week-long period, Public Health Minister Jurin Laksanavisit says. One of the three victims was a Chiang Mai man, aged 28, who was already in a high-risk group due to cirrhosis of the liver and renal disease. The other two fatalities were from Chon Buri, a woman, 28, and a 55-year-old man. The infections, between 21 February 2010 and 27 February 2010, raised the death toll to 212 and the number of people infected to 34,273. Just 17 percent of the two million people targeted have been vaccinated against the flu.
(ProMED 3/7/2010)

Viet Nam: A/H5N1 Avian Influenza strikes Khanh HoaA fresh outbreak of A/H5N1 avian influenza has been reported in central Khanh Hoa Province, killing nearly 10,000 birds. Affected areas have been decontaminated and poultry incinerated, said a spokesperson from the provincial Animal Health Unit. The latest outbreak has brought the number of provinces affected by the flu to six: Dien Bien, Nam Dinh, Nghe An, Khanh Hoa, Soc Trang and Ca Mau. The avian flu epidemic has continued to spread in these provinces, killing thousands of poultry since it re-emerged in December 2009 despite efforts to prevent contagion.
(ProMED 3/4/2010)

AmericasUSA: College flu activity stays steadyThe nation's colleges saw a very slight decrease in flu-like illnesses last week, but the attack rate stayed about the same as the previous two weeks, about three to four cases per 10,000 students, the American College Health Association (ACHA) reported on 10 March 2010. So far the patterns don't signal a third pandemic flu wave, even on a regional level. Two more hospitalizations were reported, and the vaccination level stayed the same, at about 8%.
(CIDRAP 3/10/2010)

USA: Pandemic influenza vaccine safety record still matches seasonal vaccineNearly five months after its launch, the pandemic H1N1 vaccine still appears to have a safety profile similar to that of seasonal flu vaccines, the US CDC said in an update 4 March 2010.

The CDC's report summarizes reports that it collected through its Vaccine Adverse Event Reporting System (VAERS) through 26 February 2010. The VAERS system is designed to identify potential problems that require further investigation, but it does not determine if the adverse event was caused by the vaccine. The CDC cautions that the VAERS reports are submitted voluntarily by anyone who thinks an adverse event may have occurred and often include incorrect or incomplete information.

So far, 127 million doses of pandemic vaccine have been shipped to providers, but the CDC added that the precise number of doses that have been administered is not known. (In mid February, Health and Human Services Secretary Kathleen Sebelius estimated that 70 million Americans had received the vaccine so far.) The VAERS system has received 10,172 adverse event reports for the pandemic vaccine, of which 93% are classified as "nonserious," such as injection-site soreness.

Among those reports, 6% (636) were classified as "serious," which are defined as life-threatening or resulting in death, major disability, abnormal conditions at birth, hospitalization, or extension of an existing hospitalization. The percentage of serious events for the pandemic vaccine is no different from that for the seasonal flu vaccine, the CDC said. Seasonal flu vaccines have been in use for decades, and their safety profiles have been widely praised by US and global health officials.
(CIDRAP 3/5/2010)

AfricaRwanda: Increase in cases of pandemic influenza H1N1Pandemic flu cases in Rwanda are starting to increase again after dropping in early February. A health ministry official said an increase was noted in Burera district of the Northern Province, with six confirmed cases in the past week. He said seasonal flu cases are also being reported and that a stockpile of oseltamivir (Tamiflu) is available. He added that the flu uptick calls for more vigilance but said there is no cause for alarm.
(CIDRAP 3/9/2010)

Context. Children and adolescents appear to play an important role in the transmission of influenza. Selectively vaccinating youngsters against influenza may interrupt virus transmission and protect those not immunized.

Objective. To assess whether vaccinating children and adolescents with inactivated influenza vaccine could prevent influenza in other community members.

Design, Setting, and Participants. A cluster randomized trial involving 947 Canadian children and adolescents aged 36 months to 15 years who received study vaccine and 2326 community members who did not receive the study vaccine in 49 Hutterite colonies in Alberta, Saskatchewan, and Manitoba. Follow-up began December 28, 2008, and ended June 23, 2009.

Intervention. Children were randomly assigned according to community and in a blinded manner to receive standard dosing of either inactivated trivalent influenza vaccine or hepatitis A vaccine, which was used as a control.

Results. The mean rate of study vaccine coverage among eligible participants was 83% (range, 53%-100%) for the influenza vaccine colonies and 79% (range, 50%-100%) for the hepatitis A vaccine colonies. Among nonrecipients, 39 of 1271 (3.1%) in the influenza vaccine colonies and 80 of 1055 (7.6%) in the hepatitis A vaccine colonies had influenza illness confirmed by RT-PCR, for a protective effectiveness of 61% (95% confidence interval [CI], 8%-83%; P = .03). Among all study participants (those who were and those who were not vaccinated), 80 of 1773 (4.5%) in the influenza vaccine colonies and 159 of 1500 (10.6%) in the hepatitis A vaccine colonies had influenza illness confirmed by RT-PCR for an overall protective effectiveness of 59% (95% CI, 5%-82%; P = .04). No serious vaccine adverse events were observed.

Abstract. The human respiratory tract is a major site of avian influenza A(H5N1) infection. However, many humans infected with H5N1 present with gastrointestinal tract symptoms, suggesting that this may also be a target for the virus. In this study, we demonstrated that the human gut expresses abundant avian H5N1 receptors, is readily infected ex vivo by the H5N1 virus, and produces infectious viral particles in organ culture. An autopsy colonic sample from an H5N1-infected patient showed evidence of viral antigen expression in the gut epithelium. Our results provide the first evidence, to our knowledge, that H5N1 can directly target human gut tissues.

Background. The 2009 H1N1 pandemic emerged even though seasonal H1N1 viruses have circulated for decades. Epidemiological evidence suggested that the current seasonal vaccine did not offer significant protection from the novel pandemic, and that people over the age of 50 might were less susceptible to infection.

Objectives. In a mouse challenge study with the 2009 pandemic H1N1 virus, we evaluated protective immune responses elicited by prior infection with human and swine influenza A viruses.

Conclusions. These findings indicate that in experimental animals recently induced immunity to 1918-derived H1N1 seasonal influenza viruses, and to a 1976 swine influenza virus, afford a degree of protection against the 2009 pandemic virus. Implications of these findings are discussed in the context of accumulating data suggesting partial protection of older persons during the 2009 pandemic.

Background. Influenza transmission is often associated with climatic factors. As the epidemic pattern varies geographically, the roles of climatic factors may not be unique. Previous in vivo studies revealed the direct effect of winter-like humidity on air-borne influenza transmission that dominates in regions with temperate climate, while influenza in the tropics is more effectively transmitted through direct contact.

Methodology/Principal Findings. Using time series model, we analyzed the role of climatic factors on the epidemiology of influenza transmission in two regions characterized by warm climate: Hong Kong (China) and Maricopa County (Arizona, USA). These two regions have comparable temperature but distinctly different rainfall. Specifically we employed Autoregressive Integrated Moving Average (ARIMA) model along with climatic parameters as measured from ground stations and NASA satellites. Our studies showed that including the climatic variables as input series result in models with better performance than the univariate model where the influenza cases depend only on its past values and error signal. The best model for Hong Kong influenza was obtained when Land Surface Temperature (LST), rainfall and relative humidity were included as input series. Meanwhile for Maricopa County we found that including either maximum atmospheric pressure or mean air temperature gave the most improvement in the model performances.

Conclusions/Significance. Our results showed that including the environmental variables generally increases the prediction capability. Therefore, for countries without advanced influenza surveillance systems, environmental variables can be used for estimating influenza transmission at present and in the near future.

Background. As Pandemic (H1N1) 2009 influenza spreads around the globe, it strikes school-age children more often than adults. Although there is some evidence of pre-existing immunity among older adults, this alone may not explain the significant gap in age-specific infection rates.

Methods and Findings. Based on a retrospective analysis of pandemic strains of influenza from the last century, we show that school-age children typically experience the highest attack rates in primarily naive populations, with the burden shifting to adults during the subsequent season. Using a parsimonious network-based mathematical model which incorporates the changing distribution of contacts in the susceptible population, we demonstrate that new pandemic strains of influenza are expected to shift the epidemiological landscape in exactly this way.

Conclusions. Our analysis provides a simple demographic explanation for the age bias observed for H1N1/09 attack rates, and suggests that this bias may shift in coming months. These results have significant implications for the allocation of public health resources for H1N1/09 and future influenza pandemics.

Abstract. The recent emergence and rapid spread of a novel swine-derived H1N1 influenza virus has resulted in the first influenza pandemic of this century. Monovalent vaccines have undergone preclinical and clinical development prior to initiation of mass immunization campaigns. We have carried out a series of immunogenicity and protection studies following active immunization of mice, which indicate that a whole virus, nonadjuvanted vaccine is immunogenic at low doses and protects against live virus challenge. The immunogenicity in this model was comparable to that of a whole virus H5N1 vaccine, which had previously been demonstrated to induce high levels of seroprotection in clinical studies. The efficacy of the H1N1 pandemic vaccine in protecting against live virus challenge was also seen to be equivalent to that of the H5N1 vaccine. The protective efficacy of the H1N1 vaccine was also confirmed using a severe combined immunodeficient (SCID) mouse model. It was demonstrated that mouse and guinea pig immune sera elicited following active H1N1 vaccination resulted in 100% protection of SCID mice following passive transfer of immune sera and lethal challenge. The immune responses to a whole virus pandemic H1N1 and a split seasonal H1N1 vaccine were also compared in this study. It was demonstrated that the whole virus vaccine induced a balanced Th-1 and Th-2 response in mice, whereas the split vaccine induced mainly a Th-2 response and only minimal levels of Th-1 responses. These data supported the initiation of clinical studies with the same low doses of whole virus vaccine that had previously been demonstrated to be immunogenic in clinical studies with a whole virus H5N1 vaccine.

Background. Studies have revealed that visiting poultry markets and direct contact with sick or dead poultry are significant risk factors for H5N1 infection, the practices of which could possibly be influenced by people's knowledge, attitudes and practices (KAPs) associated with avian influenza (AI). To determine the KAPs associated with AI among the Chinese general population, a cross-sectional survey was conducted in China.

Methods. We used standardized, structured questionnaires distributed in both an urban area (Shenzhen, Guangdong Province; n=1,826) and a rural area (Xiuning, Anhui Province; n=2,572) using the probability proportional to size (PPS) sampling technique.

Results. Approximately three-quarters of participants in both groups requested more information about AI. The preferred source of information for both groups was television. Almost three-quarters of all participants were aware of AI as an infectious disease; the urban group was more aware that it could be transmitted through poultry, that it could be prevented, and was more familiar with the relationship between AI and human infection. The villagers in Xiuning were more concerned than Shenzhen residents about human AI viral infection. Regarding preventative measures, a higher percentage of the urban group used soap for hand washing whereas the rural group preferred water only. Almost half of the participants in both groups had continued to eat poultry after being informed about the disease.

Conclusions. Our study shows a high degree of awareness of human AI in both urban and rural populations, and could provide scientific support to assist the Chinese government in developing strategies and health-education campaigns to prevent AI infection among the general population.

4. NotificationsAPEC EINet "Hot Topics 2" Video Conference: Lessons Learned from the 2009 Flu SeasonAPEC EINet successfully hosted its second "Hot Topics" videoconference on lessons learned from the 2009 flu season. The videoconference occurred 10 March 2010 Americas time and 11 March 2009 Asia time. Canada, New Zealand, and Thailand shared case studies regarding their preparation for, experience of, and response to the 2009 influenza season. We wish to extend our thanks to participants from Canada, New Zealand, the People's Republic of China, Singapore, Thailand and the USA. Presentations will be made available on our website shortly.

Thailand Conference on Emerging Infectious and Neglected DiseasesPattaya, Thailand, 3-4 June 2010
Outbreaks of various diseases, including SARS, avian influenza, influenza H1N1 pandemics, and the most recently chikungunya fever, continue to challenge our abilities to prepare for the emerging infectious disease threats. This conference, therefore, will facilitate national and international updating and sharing of knowledge, experiences, and scientific expertise which is crucial for handling these global threats.
Additional information and registration available at http://nstda.or.th/eid2010/.

CDC 7th International Conference on Emerging Infectious DiseasesAtlanta, Georgia, USA 11-14 Jul 2010
The 2010 International Conference on Emerging Infectious Diseases (ICEID) is the principal meeting for emerging infectious diseases organized by CDC. This conference includes plenary and panel sessions, as well as oral and poster presentations, and covers a broad spectrum of infectious diseases of public health relevance. ICEID 2010 will also focus on the impact of various intervention and preventive strategies that have been implemented to address emerging infectious disease threats.
Additional information is available at http://www.iceid.org/.

Options for the Control of Influenza VIIHong Kong, 3-7 Sep 2010
Options for the Control of Influenza VII is the largest forum devoted to all aspects of the prevention, control, and treatment of influenza. As it has for over 20 years, Options VII will highlight the most recent advances in the science of influenza. The scientific program committee invites authors to submit original research in all areas related to influenza for abstract presentation. Accepted abstracts will be assigned for oral or poster presentation.
Additional information is available at http://www.controlinfluenza.com.